Cardiovascular Journal

Permanent URI for this collection

https://imsear.searo.who.int/handle/123456789/150287

Editor: Dr Mohammad Ullah Firoze

ISSN: 2071– 0917
Frequency: Half-yearly

Language: English

Open Access Peer-reviewed journal

Web site: https://www.banglajol.info/index.php/CARDIO

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Now showing 1 - 20 of 254

Comprehensive Textbook of Echocardiography.
(2014) Nanda, Navin C
A Tale of Two Surgeons.
(2015) Hosain, Suman Nazmul
Cardiac transplantation is one of the greatest medical marvels of the twentieth century. Performing this miraculous operation on 3rd December 1967, Dr. Christiaan Barnard, an unknown surgeon from the then apartheid state of South Africa suddenly became an international celebrity. Probably no single procedure in the history of medicine had attracted so much media and public attention. But there were many who thought that he didn’t deserve much of this glory. A lion share of this should have gone to somebody else. Although Barnard completed the final step in the road to transplant, it was the end product of serious research work carried out in many centers around the World. Most important was Stanford University Medical Center, Palo Alto, California USA, where Dr. Norman Edward Shumway was engaged in transplantation related research work along with his junior colleague Dr. Richard Lower. The most of the techniques used in cardiac transplantation today were actually developed by Dr. Shumway and his team. Barnard worked in the same unit with Shumway at University of Minnesota when he came to USA. He visited USA again in 1966 when he observed the works of Shumway’s research partner Dr. Richard Lower. During both of his visits he had adopted many techniques from the research work of his American counterparts and later used in his unique accomplishment. Barnard succeeded utilizing techniques developed through Shumway’s painstaking work over the years depriving Shumway much of the glory he deserved. Both later on continued in the development of transplantation when most others left because of poor outcome. Shumway excelled the technical details and Barnard drew media and public attention to the importance of this procedure. After almost five decades the name of Barnard is still well known by the common people around the World; whereas Shumway remains unknown even to most of the cardiac surgeons as well. This was the destiny of the two main heroes credited behind this exciting medical accomplishment. Here lies a very interesting story, the tale of two surgeons.
Bentall Surgery for Aortic Root Aneurysm in a Patient with Marfan Syndrome.
(2015) Maruf, Mohammad Fazle; Hossain, Nazmul; Akter, Tahmina; Chowdhury, Asif Ahsan; Kamrul, hasan; karim, Rezaul; Ahsan, N A Kamrul
A 34 yrs old man of marfan syndrome, visited us with the complaints of palpitation, easy fatigability and chest discomfort for last 1year. He was pointed out to have the aortic root enlargement with severe aortic regurgitation & mild mitral regurgitation by echocardiography and CT angiogram. We excised the aneurysm, implanted a composite graft with prosthetic valve conduit (Bentall operation), directly attached the coronary arteries to the aortic graft, and made the distal anastomosis to the divided aorta. Postoperative course was uneventful. To our knowledge, this is the first successful case of Bentall operation in national Institute of cardiovascular Diseases.
Sudden Cardiac Death in Three Generations of the Same Family: A case report.
(2015) Khan, M M Zahurul Alam; Chowdhury, Abdul Wadud; Khan, Tunaggina Afrin; Alam, Md Nur; Sabah, Khandaker Md Nurus; Saleh, Mohammed Abaye Deen
Every one of us has heard about tragic and sudden death of a healthy young person and which is often stated as ‘inexplicable’. The current case report focuses on a 20 year old young man with hypertrophic cardiomyopathy facing premature death with history of similar sudden premature death of his grandmother, father and brother. Hypertrophic cardiomyopathy is the commonest cause of sudden cardiac death in young adults and is also an important substrate for heart failure disability at any age.
Ventricular Fibrillation with Brugada Syndrome: A Case Report.
(2015) Nabi, Shaila; Tushar, Asif Zaman; Ferdaushi, Umme Habiba; Islam, Mainul; Uddin, Farhad; Ali, M Atahar
Brugada syndrome is a potentially lethal and eminently treatable entity that may present with palpitations or syncope. This article presents the case of a young patient with Brugada syndrome and reviews key features in the epidemiology, pathophysiology, diagnosis, treatment and prognosis of this condition.
Atrial Infarct: An Easily Missed Reality with Hidden Threat – A case report with Review of Literature.
(2015) Saleh, Mohammed Abaye Deen; Chowdhury, Abdul Wadud; Hasan, Pratyay; Kabir, Rezwan Syed; Nahar, Khyrun; Sabah, K M N; Amin, Mohammad Gaffar; Islam, Kazi Nazrul
Atrial infarction is a very rare diagnosis. Though available literature suggests, the condition per se may have been not so rare. Over the past few decades, atrial infarction have been reported several times, even some case series have been reported, but there is no consensus on the diagnosis of this condition, and its true importance also has not been understood completely. Previous works have shown that this condition is associated with several serious complications; hence recognition of this condition in early period is important, which is at the same time not so easy due to subtlety of the known features and less availability of information. We report a case of 70 year old Muslim, Bengali, male suffering from acute coronary syndrome, in whom, right atrial infarction was recognized by electrographic features, which is very rarely diagnosed with confidence in ante-mortem patients. Since, in Bangladesh, post-mortem autopsy to find out causes behind cardiac death is not done routinely and in the light of possibility of serious life-threatening complications, ante-mortem diagnosis of atrial infarction is necessary. So, Cardiologists should be aware of this uncommon condition.
Increasing Prevalence of Hypertension in Bangladesh: A review.
(2015) Koly, Kamrun Nahar; Biswas, Tuhin; Islam, Anwar
Hypertension is a major public health problem globally in both the developed and developing countries. In Bangladesh, approximately 20% of adult and 40–65% of elderly people suffer from hypertension. According to Non Communicable Disease risk factors survey, one third of the Bangladeshi population never measured their blood pressure. The prevalence of self reported hypertension was 12.5% (men 10.9% and women 13.9%). Many risk factors underlying hypertension have been identified including non- modifiable factors such as age, gender, genetic factors, and race, as well as modifiable factors including overweight, high sodium intake, and reduced physical activity. The aim of this review was to present the scenery of hypertension and as well as present the exponential trend of hypertension in Bangladesh. We included 9 studies for the review that met the inclusion criteria and study objectives. Analyses of exponential trend reveled an increase in hypertension prevalence among adult population at a rate of 0.04 (R=0.33) per year. This review studies have demonstrated that interventions aimed at changing these modifiable factors might contribute to prevent the development of hypertension.
Multivessel Percutaneous Coronary Intervention in Patients with Acute ST-segment Elevation Myocardial Infarction in Same Sitting.
(2015) Islam, A H M Waliul; Munwar, Shams; Bhuiyan, Azfar H; Talukder, Sahabuddin; Reza, A Q M; Ahmed, Tamzeed; Islam, Nighat; Siddique, Atique bin; Yousuf, Intekhab; Shohel, Shaifur Rahman; Tanvir, Sarder Md; Karim, Aparajita; Ahmed, Tanvir; Alam, M S
Background: Aim of the study was to evaluate the primary procedural success of Multivessel Percutaneous coronary intervention in patients with acute ST-segment elevated myocardial infarction at the same sitting. Methods: Total 23 (13.4%) patients were enrolled in this very preliminary study, among the total 171 patients who had primary PCI at our center from Jan 2010 to February 2015. Among them, Male: 20 and Female: 3. Total 52 stents were deployed in 46 territories. Mean age were for both male and female were 54 yrs. Associated coronary artery disease risk factors were Dyslipidemia, High Blood pressure, Diabetes Mellitus, positive family history for coronary artery disease and Smoking. Results: Among the study group; 17(74%) were Dyslipidemic, 11(47.8%) were hypertensive; 8(34.8%) patients were Diabetic, positive family history 4(17.4%) and 9(39%) were all male smoker. Female patients were more obese (BMI: M 26: F 27). Common diagnosis at admission based on ECG evidence was; Inferior wall myocardial infarction: 12 (52.2%), Anterior wall myocardial infarction 9(39.1%) and lateral 2(8.7%). Common stented territory was left anterior descending artery 9(39.1%), right coronary artery 7(30.4%), and left circumflex artery 7(30.4%). Stent used: Bare metal stent 3 (5.7%), DES: 49 (94.2%). Among the different drug eluting stents, Everolimus 26 (52%), Sirolimus 8(15.4%) and Zotarolimus 9(17.3%), Paclitaxel 2 (3.8%), Biolimus 2 (3.8%), Genous 2 (3.8%). Conclusion: In the current prospective non randomized study, we found that the multivessel primary PCI for ST elevation myocardial infarction with non-culprit vessel are suitable for PCI at the same sitting with better in-hospital and 1 yr survival outcome.
In-Hospital Outcome of Older and Younger Patients with Acute Coronary Syndrome.
(2015) Kabir, S M Eftar Jahan; Chowdhury, Abdul Wadud; Amin, Md.Gaffar; Alam urus, Sarwar Mohammad Sabah Khandker Md.N; Abdullah, Abu Sadique; Hossain, Mofazzal; Zahid, Abu; Faruk, Chowdhury Omar; Khan, Tunaggina Afrin
Background: Acute coronary syndrome is a cardiac emergency. It is increasingly common in younger peoples. Management of elderly peoples is difficult due to their associated comorbidity. This study tried to compare the in-hospital outcome of the younger and older patients with acute coronary syndrome. Methods: The study was a comparative cross sectional study. Clinical and biochemical evaluation was done in hospital settings. A total number of 120 patients were included in the study and divided into two groups according to distribution of age. In group I there were elderly groups of aged >60 yrs. and in group II there were patients within the age 40 to 60 yrs. All the data were collected systematically in a preformed data collection form. Results: Group I populations had more in hospital stay and more complications than group II. Conclusion: The study revealed significant association with age and outcome of Acute coronary syndrome patients. Complications of acute coronary syndrome increase as the age of the patients increases.
Association of Glycosylated Haemoglobin Level with the Severity of Coronary Artery Disease in NSTEMI Diabetic Patients.
(2015) Salim, Mahmod Mohammad; Fazila-Tun-Nesa, Malik; Arif Rahman, Mohammad; Hossain, Mohammad Delwar; Masum, Mandal Md Raihan
Background: Relation between diabetes mellitus and ischemic heart disease is well established. But the effect of HbA1C on severity of coronary artery disease remains uncertain in non-ST elevation myocardial infarction and diabetic patient. Objective of our study was to know the relationship of HbA1C with the severity of coronary artery disease. Methods: In this cross sectional analytical study a total of 104 NSTEMI diabetic patients were enrolled by purposive sampling. They were divided into two groups according to the level of HbA1C, Group-I patients having HbA1C<7% and Group-II patients having HbA1C >7%. Vessel score and Gensini score was calculated from coronary angiogram and compared between groups. Results: Single vessel disease were significantly higher in group-I compared to Group-II( 38.5% vs 7.7% in Group-I vs Group-II,p<0.05). Double vessel disease were higher in group-II compared to Group-I but the difference was statistically not significant (42.3% vs 48.1% in Group-I vs Group-II respectively (p>0.05). Triple vessel disease were significantly higher in group-II compared to Group- I (19.2% vs 44.4% in Group-I vs Group-II,p<0.05). Mean Vessel score was higher in Group-II compared to Group-I(1.73 ± 0.86 vs 2.50 ±0.70 in Group-I vs Group-II, p<0.05). Mean Gensini score was higher in Group-II compared to Group-I (44.6 ± 38.4 vs 76.9 ± 44.6 in Group-I vs Group-II, p<0.05). There were significant positive linear correlation between HbA1C and Vessels score and Gensini score (p<0.05). Conclusion: This study may be concluded that the presence of HbA1C >7% are associated with of severe coronary artery disease in NSTEMI with diabetes mellitus
Comparison of Diagnostic Criteria to Detect Undiagnosed Diabetes in Acute Coronary Syndrome Patients with Admission Hyperglycemia.
(2015) Alam, Mohammad Sarwar; Khan, HI Lutfur Rahman; Chowdhury, Abdul Wadud; Sabah, Khandker Md. Nurus; Amin, Md Gaffar; Kabir, SM Eftar Jahan; Abdullah, Abu Sadique; Hossain, Mofazzal; Khan, Tunaggina Afrin; Shahidulla, Md Sk
Background: Diabetes mellitus is one of the most important risk factors of coronary artery disease. Admission hyperglycemia adversely influences the outcome of acute coronary syndrome patients. The study was conducted to compare the various diagnostic methods for the detection of undiagnosed diabetes mellitus in acute coronary syndrome patients with admission hyperglycaemia in Bangladeshi population. Methods: It was a cross sectional comparative study involving 157 patients with admission blood glucose level e”7.8 mmol/l. Fasting plasma glucose, Glycated haemoglobin, pre-discharge oral glucose tolerance test was measured in all subjects and comparison of performance of different methods was done. Results: Oral glucose tolerance test revealed that in spite of admission hyperglycaemia, 57 (36.3%) patients were diabetic and 52 (33.12%) patients had impaired glucose homeostasis and 48 (30.57%) patients had normal glucose metabolism. Undiagnosed diabetes could not be adequately predicted with admission plasma glucose, fasting plasma glucose or HbA1c alone (area under the ROC curve 0.589, 0.825 and 0.852 respectively). Conclusion: Admission hyperglycaemia does not diagnose diabetes reliably in a stressful condition like acute coronary syndrome. Although neither admission plasma glucose, fasting plasma glucose, nor HbA1c level were as good as oral glucose tolerance test in detecting true diabetes, but combined fasting plasma glucose & HbA1c were found to be more sensitive & specific screening tool for detecting unknown diabetes in acute coronary syndrome patients with admission hyperglycaemia.
Association of GRACE Risk Score with Angiographic Severity of Coronary Artery Disease in patients with ST Elevation Myocardial Infarction.
(2015) Saha, Tapash; . Khalequzzaman, Md; Akanda, Md. Abdul Kader; Saha, Simu; Tushar, Asif Zaman; Ahmed, Rashid; Saha, Gouranga Kumar; Ullah, Mohammad
Background: Clinical guidelines recommend that optimal management of acute coronary syndrome should include patient risk stratification. Predicting the anatomical extension of coronary artery disease is also potentially useful for clinical decision. The objective of our study is to determine whether the GRACE risk score correlates with the angiographic extent and severity of coronary artery disease in patients with ST elevation myocardial infarction. Methodology: 50 patients diagnosed with Acute Myocardial Infarction were included as sample by purposive sampling method. GRACE risk score for each patient was calculated and the patients were divided into groups according to the GRACE risk score: low risk (<108); intermediate risk (109-140). The severity of the coronary artery disease was assessed by vessel score and Gensini score. Relation between Grace score and Gensini score was evaluated. Results: Mean GRACE score of study population was 128.3±22.7. Mean Gensini score was 23.88±17. Mean Gensini score were 15.47±10.4, 27.75±9.26 and 31.52±16.91 in low GRACE risk group, intermediate group and high risk group respectively and the difference of mean Gensini score was statistically significant (p=0.006). In our study correlation co-efficient between GRACE risk score and Gensini score was r=0.17 (p=0.04). Multiple regression analysis showed that age more than 50 years (p=0.02), ST segment deviation (p=0.01), smoking (p=0.02), hypertension (p=0.01) were able to independently predict patients with severe CAD. Conclusion: Our study demonstrates that the GRACE risk score carries a significant positive correlation with the coronary artery disease severity in patients with STEMI.
Comparison of Different Risk Factors and Coronary Angiographic Profile in Younger and Older Patients with Ischeamic Heart Disease.
(2015) Islam, Kazi Nazrul; Chowdhury, Abdul Wadud; Khandaker, Azizul H; Sabah, Nurus Khandker Md; Amin, Md. Gaffar; Kabir, Syed Rezwan; Saleh, Mohammed Abaye Deen
Background: Due to socio-economic improvement and changes in the life style, ischeamic heart disease is becoming a major burden to our health care system. In recent years, the incidence is increasing among younger age groups as well. Methods: A total of 120 patients with ischeamic heart disease admitted for coronary angiogram were included in the study and were divided into two groups. Among them, 60 younger patients were in Group-I (d” 40 years of age); 60 older patients in Group-II (>40 years of age). We compared demographic profiles, different risk factors and angiographic profiles between two age groups. Results: Among the common risk factors, smoking (63.3% vs 40%, p=0.011) & family history of ischeamic heart disease (21.7% vs 8.3%, p=0.040) were more common in younger group. Whereas, hypertension (41.7% vs 65.0%, p=0.010) and DM (18.3% vs 36.7%, p=0.024) were more common in older patients. Serum Homocysteine level was found significantly higher in younger patients (30.0% vs 13.3%, p=0.026). In group-I. coronary angiography revealed normal coronaries in 15 patients (25%), single vessel disease in 29 (48.3%) and multi-vessel disease in 16 patients (26.6%). Whereas, 40(66.6%) patients in group-II were found to have multi-vessel disease and 2 of them had significant left main coronary disease. However, young patients who had high serum homocysteine level showed more angiographic severity than older patients. Conclusion: There are significant differences in the clinical, biochemical and angiographic profile of young patients with ischeamic heart disease as compared to older patients. Young patients with ischeamic heart disease has got less angiographic severity, except in those with high serum homocysteine level.
Clinical Presentation of Left Atrial Myxoma in Relation to Anatomic and Pathologic Type.
(2015) Rahman, S M Mahbubur; Kibria, M Golam; Rahim, A M Asif; Hosain, Nazmul; Quashem, M Abul
Background: Atrial myxoma is the most common benign cardiac neoplasm. Most of the case series have focused on the variable clinical presentation of myxoma rather than its gross and microscopic features. The objective of our study was to evaluate prevalence of different morphologic types of myxoma and to correlate with their clinical presentations. Methods: 68 patients were included in the study. The study population was divided into two groups- Group-A (n-18) patients having soft (papillary) tumor in the left atrium, Group B (n=50) patients having solid tumor in the left atrium. Results: 88.3% patients suffered illness more than 12 months. 92% of the solid myxomas were located in the septal wall compared to 55.6% of the papillary myxomas (p = 0.031), while one-third (33.3%) the papillary tumors were found in the left atrial free wall compared to only 4% of the solid myxomas (p = 0.048). Fever, congestive heart failure and dyspnoea were significantly predominant in patients with solid myxomas (72% vs. 44.4%, p = 0.036; 92% vs. 22.2%, p < 0.001 and 88% vs. 55.6%, p = 0.010 respectively). Atrial fibrillation and neurologic manifestations were more frequently encountered in the papillary myxoma group. No statistically significant difference was found between the groups (p>0.05) by postoperative complication during in hospital follow up but one mortality in each group. Conclusion: Our findings lend support to the view that different gross left atrial Myxoma tumor types and tumor location predict presentation.
Relationship between P Wave Dispersion and Left Ventricular Diastolic Dysfunction in Hypertensive and Ischemic Heart Disease Patients.
(2015) Tushar, Asif Zaman; Majumder, A A S; Azam, S T M Abu; Ullah, Mohammad; Ahmed, Rashid; Saha, Tapash; Islam; Rahman, Md. Arifur
Background: There is growing recognition that congestive heart failure caused by a predominant abnormality in left ventricular diastolic function is common and causes significant morbidity and mortality. Diastolic function usually declines before systolic function, and this precedes clinical signs. 12-lead electrocardiogram is a commonly used tool to assess left atrial enlargement, which is a marker of left ventricular diastolic dysfunction. We investigated the relationship between P wave dispersion, which is easily measured on the surface electrocardiogram and left ventricular diastolic function. Methods: There were 100 patients: 50 with diastolic dysfunction and 50 without. P wave dispersions were calculated by measuring minimum and maximum P wave duration values on the surface electrocardiogram. The relationships between P wave dispersion and echocardiographic measurements of diastolic dysfunction were assessed. Results: Maximum P wave duration was observed significantly (p=0.001) in patients with left ventricular diastolic dysfunction (119.60±8.2 ms vs 114.0±6.4 ms). Minimum P wave duration was observed significantly (p=0.001) higher in patients without diastolic dysfunction (72.6±7.5 ms vs 62.70±7.4 ms). P wave dispersion was observed significantly (p=0.001) higher in patients with left ventricular diastolic dysfunction (56.6±6.3 ms vs 41.5±5.2 ms). When patients were grouped according to grades of diastolic dysfunction, P wave dispersion was observed sequentially increased among 3 grades of left ventricular diastolic dysfunction (55.8±5.2 ms vs 55.9±7.0 ms vs 61.4±4.7) but the differences were not statistically significant (p=0.09). Conclusion: We conclude that P wave dispersion increases in diastolic dysfunction of LV. When clinical and echocardiographic variables are taken into account, there is a weak but significant correlation between P wave dispersion and left ventricular ejection fraction.
Effect of Subvalvular Changes on Mitral Valve Leaflets Excursion after Percutaneous Transvenous Mitral Commissurotomy.
(2015) Mannan, Md. Abdul; Majumder, A A S; Hossain, Solaiman; Shaha, Chandan Kumar; Khair, Md. Abul; Ullah, Mohammad; Rahman, Md. Toufiqur
Background: Aim of our study was to predict the effect of subvalvular changes on mitral valve leaflets excursion in a patient with mitral stenosis following percutaneous trans-venous mitral commissurotomy. Methods: Total of 60 patients of severe mitral stenosis were enrolled in the study. Transthoracic echocardiography was done on the day before percutaneous trans-venous mitral commissurotomy and 24-48 hours after percutaneous trans-venous mitral commissurotomy. Subvalvular area, anterior and posterior leaflets excursion were recorded. Results: Following percutaneous trans-venous mitral commissurotomy there were significant increase in anterior leaflet excursion from 1.8 ± 0.2 to 2.2 ± 0.2cm (p=<0.001), posterior leaflet excursion from 1.5±0.2to1.8 ± 0.2cm (p<0.001) . Subvalvular splitting areas was from 0.8 ± 0.2 to1.2 ± 0.2cm²(p=<0.001). Pulmonary arterial systolic pressure and left atrial diameter were significantly reduced respectively 55.6 ± 19.5 vs. 31.6 ± 9.5 mmHg,(p < 0.001) and 4.3 ± 0.6 cm vs. 3.8 ± 0.6 cm (p < 0.001). Post percutaneous trans-venous mitral commissurotomy subvalvular splitting area was found to be the predictor of increased excursion of both anterior and posterior mitral leaflets. Conclusion: percutaneous trans-venous mitral commissurotomy is associated with immediate significant changes in mitral valve morphology in terms of splitting of fused mitral commissures, increased valve leaflets excursion and splitting of the subvalvular structures. Post percutaneous trans-venous mitral commissurotomy subvalvular splitting area was found to be the predictor of increased excursion of both anterior and posterior mitral leaflets.
Reduction of Peri - Procedural Myocardial injury by Loading dose of Atorvastatin during Elective Percutaneous Coronary Intervention.
(2015) Chandan, Kumar Saha; Hossain, Solaiman; Mannan, Md. Abdul; Ullah, Mohammad; Faruque, Md
Background: The purpose of the study was to find the effect of loading dose of atorvastatin on the reduction of myocardial injury resulting from percutaneous coronary intervention (PCI). Methods: A total 100 consecutive patients were included in this study of which 50 patients were in the group I who were treated with a loading dose of atorvastatin and the rest 50 patients were in the group II who were treated without the loading dose of atorvastatin.The occurrence of myocardial injury was measured by serum cTn-I level in patients undergoing PCI with or without loading dose of atorvastatin.
Hypertension : Guidelines and Bangladesh Perspective.
(2015) Majumder, Abdullah Al Shafi
Trans-catheter Treatment of Lutembacher Syndrome -A Case Report.
(2015) Salam, A B M Abdus; Islam, S K Ziarat; Hasan, Kazi Abul; Azad, Saiful Islam; Haque, Ataul; Shariar, Abdullah; Zakia, Naznin Umme; Mita, Shahina Akter
Lutembacher syndrome is a rare combination of congenital Atrial Septal Defect (ASD) and acquired Rheumatic Mitral Stenosis (MS).It is usually treated by surgical repair with potential risk of cardiopulmonary bypass. With the advancement of interventional methods of treatment it is amenable to nonsurgical transcatheter management. We are reporting a case of Lutembacher syndrome that was successfully treated with percutaneouos Inoue balloon mitral valvuloplasty and device closure of atrial septal defect.
Total Arterial Coronary Revascularization with Aorto-bifemoral Bipopliteal Bypass – A Case Report.
(2015) Zahangir, Nuruddin Mohammod; Ahmad, Syed Tanvir; Ahmed, Firoz; Kabir, Md. Mainul; Khan, Tamjid Mohammad Najmus Sakib; Hossain, Nazmul; Ahmed, Niaz; Naik, Madhava Janardhan
The management of combined Coronary Artery Disease and Peripheral Vascular Disease is a challenge and brings with it numerous clinical dilemmas. The 56 year old gentleman presented to our department with significant triple vessel disease with occluded lower end of aorta just before bifurcation and occluded bilateral superficial femoral arteries. CABG with aorto-femoral and femoro popliteal bypass was done on the same setting. On 12th postoperative day he was discharged from hospital in good general condition. Follow up after 6 months of operation the patient is doing well and free of chest pain and claudication pain.

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